4D Breast, Oncology, Palliative Care

Question 1

Breast conditions

1. Duct ectasia. Symptoms? (2) Common age of presentation?

Answer 1

1. Duct ectasia: non-malignant breast disease with thick green nipple discharge, commonly with a peri-areolar lump, occurring with breast involution (menopausal change).
   Duct ectasia reflects a shortening and widening of the terminal breast ducts around the nipple.

Question 2

Breast cancer - hormonal therapy

1. Tamoxifen
   - Class of drug?
   - Indication?
   - Side effects?
2. Anastrozole.
   - Class of drug?
   - Indication?
   - Side effects?

Answer 2

1. Selective oestrogen receptor modulator (SERM), which blocks oestrogen from acting at its receptors.

Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. Tamoxifen for 5 years after diagnosis in PRE- and PERI-menopausal women.

Side effects: increased risk of endometrial cancer, VTE and menopausal symptoms.

2. Aromatase inhibitor. Reduces the oestrogen levels in the body and is typically given for 5 years.

Used in the management of hormone-receptor-positive (ER +ve) breast cancer patients in POST-menopausal women.
Anastrozole = After menopause

Side effects: Hot flushes, insomnia and low mood.

Question 3

Tumour markers

1. CA 15-3
2. CA 19-9
3. CA 125
4. Alpha-fetoprotein (AFP)
5. Neuron-specific enolase (NSE) or cytokeratin fragment (CYFRA) 21-1
6. Bombesin
7. CEA (Carcinoembryonic Antigen)
8. Alpha-fetoprotein (AFP) & Beta-HCG

Answer 3

1. Breast cancer
2. Pancreatic cancer
3. Ovarian cancer
4. Hepatocellular carcinoma
5. Lung cancer
6. “Mr Bombastic, small cell and gastric”
7. Colorectal cancer (also pancreatic cancer, IBD, smoking)
8. Testicular teratoma (Nb. seminoma more common)

Question 4

Oncological emergencies

1. Superior vena cava obstruction
   Symptoms?
   Treatments?
2. Neutropenic sepsis
   Symptoms?
   Treatment?

Answer 4

1. Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC. It is most commonly associated with lung cancer.

Symptoms: Dyspnoea, swelling of face, neck and arms , conjunctival and periorbital oedema,
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension
NB. peripheral oedema WITHOUT pulmonary oedema.

Treatments: Endovascular stenting, radical chemotherapy, chemo-radiotherapy.

2. LOW temp.
   Blood cultures and IV abx within 1 HOUR

Question 5

Cytotoxic agents

‘Toxicity bear’

What drug is associated with the following:

1. Cardiomyopathy
2. Haemorrhagic cystitis
3. Peripheral neuropathy
4. Neutropenia
5. Pulmonary fibrosis
6. Ototoxicity, nephrotoxicity, hypomagnesaemia.
7. Myelosuppression, liver fibrosis and oral mucositis

Answer 5

1. Doxorubicin (lymphoma)
2. Cyclophosphamide (lymphoma, leukaemia)
3. Vincristine (lymphoma)
4. Docetaxel (breast and lung cancers)
5. Bleomycin (lymphoma)
6. Cisplatin
7. Methotrexate

Question 6

Human Papillomavirus (HPV).

1. What strains cause cervical cancer?
2. What strains cause genital warts?
3. What strains cause common warts?

Answer 6

1. 16, 18 & 33
2. 6 & 11 (and thereby low risk for cervical cancer)
3. 2, 7 & 22 cause common warts.

Question 7

Metastases

1. Which 5 cancers most commonly metastasise to BONE?
2. Where does BREAST cancer typically metastasise to?

Answer 7

1. BLT with ketchup and pickles

Breast (both lytic and sclerotic lesions)
Lung (lytic)
Thyroid
Kidney
Prostate (sclerotic)

Osteoblastic lesions (sclerotic)
Osteolytic lesions

2. Breast metastasis: 2L’s 2B’s
   Lungs
   Liver
   Bones
   Brain

Question 8

Drug treatments

1. Spinal cord compression (neoplastic)

Answer 8

1. Oral dexamethasone 8mg BD
   (or 16mg IV stat?)

Question 9

What are the differences between

Multiple endocrine neoplasia type I

and

Multiple endocrine neoplasia type II?

Answer 9

MEN type IIb - autosomal dominant.
Sx - phaeochromocytomas, medullary carcinoma of the thyroid

Question 10

DRUGS for end of life care
- Class of drug
- Therapeutic effects

1. Glycopyrronium bromide
2. Midazolam
3. Benzydamine hydrochloride (mouthwash or spray)

Answer 10

1. Anticholinergic (antimuscarinic) agent → inhibits the action of acetylcholine (does not cross BBB so does not cause confusion)

• Reduces production of saliva → reduces respiratory secretions
• Alleviates bowel colic

hyoscine hydrobromide, hyoscine butylbromide have similar actions.

2. Midazolam - benzodiazepine. Manage terminal agitation and restlessness.
   - Sedation
   - Muscle relaxation
3. Mouthwash or spray - painful mouth . AKA Difflam. Numbs throat in paediatric tonsillitis also.

Question 11

Performance status informs cancer treatment
Describe categories 0-5?

Answer 11

0-1 : offer cancer treatment
2 : Individual basis
3-5 more side effects from treatment - risks outweigh benefits. Not suitable for cancer treatment.

Question 12

Side effects of chemotherapy

Answer 12

Important - neutropenic sepsis

https://www.healthline.com/health/cancer/effects-on-body#circulatory-and-immune

Question 13

Immunotherapy

1. Imatinib
2. Herceptin

Answer 13

1. CML. Acts on BCR-ABL translocation (Philadelphia chromosome)
2. HER2+ve breast cancer

Question 14

OSCE Tips

PHYSICAL EXAMINATION
Look for radiotherapy tattoos

Question 15

Explain cancer treatments
1. Radioisotope therapy

Answer 15

1. Thyroid, iodine

Question 16

Lung Cancer

Red flags?

Answer 16

small cell 13%
- very aggressive even if small
lesion

Red flag - pain at night

Tracheal deviation caused by one of 3 things - mass, fluid or air (pneumothorax).

Investigations

Question 17

Confused patient - what to exclude?

Answer 17

Confused patient
- Exclude UTI, chest infection, sepsis (Urine dipstick / MSU / CXR)
- Hypercalcaemia (Bloods)
- Dehydration (U&Es)
- Brain mets, stroke (Head CT)

Hypercalcaemia treatment
- IV fluids
- IV pamidronate 60-90mg over 2 hours.

Question 18

Prostate cancer most common type?

Describe Gleason score 1 -5

Answer 18

95% adenocarcinoma
5% other eg carcinoma

Investigation
- PSA x2
- DRE
- Pre-biopsy MRI
- Transperineal Biopsy

Staging - CT scan if PSA >40, bone scan, PET CT if ?mets.

Gleason scoring 1-5, 5 is worst (undifferentiated, more aggressive).
eg 3+4 means 3 most common, 4 second most common.

Question 19

Describe TNM staging 1-4 in prostate

Answer 19

Question 20

Treatment - for each stage?

Answer 20

Early (T1-2, N0, M0)

Observation
‘Watchful waiting’
‘Active surveillance’

Radical treatment
Surgery
Prostatectomy
Pelvic lymph node dissection
Radiotherapy
External beam radiotherapy
Interstitial brachytherapy
+/- Neoadjuvant or adjuvant hormone therapy

Question 21

T1 or T2 weighted MRI?

Answer 21

T2

This image - T1?

Question 22

Level of neutropenia?
Platelet count to need platelet transfusion?

Answer 22

Neutrophils <1
Neutropenic sepsis - eg Tazocin or Meropenem, +- Gent +- Vanc

Platelets - 10
If infection - 20
Surgery - 50?

Question 23

What is frailty?
How is it measured?

Answer 23

Ability to bounce back. Takes longer to recover, and does not recover back to previous level of function.

Can be described as an age-related condition characterised by a decline in physiological capacity across several organ systems, which results in a higher vulnerability to stressors and unfavourable outcomes

Rockwood frailty score.

Question 24

Random facts

1. Vivid dreams
2. Falls
3. Visual hallucinations
4. What blood abnormalities cause confusion
5. Normal pressure hydrocephalus symptoms?

Answer 24

1. Can mean cardiac ischaemia / atypical MI no chest pain
2. All falls are ‘mechanical’ not useful term. Not remembering to hit the floor means LOC.
3. Dementia with Lewy bodies
4. Hypercalcaemia, hyponatraemia, B12 deficiency
5. Wet, wobbly wacky

Question 25

AMTS - What are the 10 questions?

Answer 25

Question 26

Pressure Ulcers - describe grades 1-4? Describe a moisture lesion.

Answer 26

Question 27

What is the tool for reviewing older people's medicines? What tool to find anticholinergic burden?

Answer 27

https://www.cgakit.com/m-2-stopp-start ACB Calculator (anti-cholinergic burden) https://www.acbcalc.com OR Medichec http://www.medichec.com

Question 28

Breast anatomy 1. Ligaments that hold up / creates shape? 2. Sebaceous glands lubricating apple? 3. What arteries supply the breast? 4. Embryology of breast 5. Area in the axilla called? 6. Order of lymph node spread of cancer?

Answer 28

1. Suspensory ligaments of Cooper. In cancer can cause pitting. 2. Areolar glands of Montgomery 3. Internal thoracic arteries (perforating branches), Axillary - lateral thoracic, thoraco-acromial. 4. Invagination of ectoderm (7 weeks) → milk lines (axilla to inguinal) small portion persists in thoracic region 5. Axillary tail of Spence 6. Lateral → central → apical.

Question 29

Breast surgery Describe level 1-3 node clearance

Answer 29

Question 30

Alzheimer's Disease Speed on onset? Symptoms? Brain structural changes? Drugs for treatment?

Answer 30

1st most common dementia AD - very slow onset over years. Slow, progressive decline. Forget words for objects 'the thing' word doesn't come back. Loss of insight - not worried about their memory problem Amyloid plaques. Brain atrophy of medial temporal lobe (temporal lobe is where hippocampus is - memory). Widening of sulci, narrowing of gyro, ventricular enlargement, amyloid plaques, neurofibrillary tangles (tau protein). Treatment mild - moderate (eg still live in own home) Cholinestrase inhibitors - Donepezil, Rigastigmine, Galantamine. + Memantine (NMDA antagonist) moderate-severe + Risperidone, Haloperidol (Antipsychotics - severe - last resort)

Question 31

Vascular dementia

Answer 31

2nd most common dementia Stepwise deterioration, fluctuating course. Vascular risk factors. -blood pressure, MI, CVA, smoking. Mini strokes damage in the brain. Treatment - No mediations

Question 32

Dementia with Lewy bodies

Answer 32

3rd most common dementia Closely linked to Parkinsons. Parkinson's symptoms + dementia - rigidity, tremor, bradykinesia. - Visual hallucinations - Fluctuating cognition - REM sleep disorder (not appropriately paralysed during REM sleep - kicking, screaming etc) Diagnosis - Clinical (symptoms) Don't give dopamine VS Parkinson's disease dementia Motor symptoms precede others by > 12 months.

Question 33

Frontotemporal dementia aka Pick's disease

Answer 33

4th most common demential Frontal and temporal lobes Behaviour and personality change - disinhibition, eg gambling. Speech probems (Broca's - frontal, Wernike's - temporal). Memory generally ok Onset 45-65 years

Question 34

Breathlessness - Causes? - Treatments?

Answer 34

NON-MEDICAL TREATMENT - Breathlessness group at PBL - breathing exercises - Fans MEDICAL TREATMENT - Benzodiazepines for panic related to breathlessness

Question 35

Pain management

Answer 35

Oromorph 2.5-5mg 2-4hrly Oxycodone 1.25-2.5mg see slide

Question 36

Midazolam - dose?

Answer 36

Midazolam - 10-60mg over 24 hours. For agitation in palliative care. Antiemetic - Levomepromazine 6.25 / 24 hours Ondansetron Haloperidol Cyclizine (brain mets) Volume - 17ml Diluent - water for injection PRNs always 4 things (put timing interval on chart) - Morphine 1/6 of 24hr total at least 2.5mg PO - Midazolam 2hrly - Hyoscine 20mg 2hrly (secretions) - Levomopromazine 6.25-12.5mg (nausea/agitation) 4-8 hourly

Question 37

1. Oral oxycodone → sub cut oxycodone 2. Oral morphine → oral oxycodone

Answer 37

1. Oral oxycodone → sub cut oxycodone (divide by 2) 2. Oral morphine → oral oxycodone (divide by 2).

Question 38

Management of breathlessness

Answer 38

Conservative - sit up, repositioning, fan Medical - Morphine, furosemide

Question 39

What opiate depending on eGFR? >60 30-60 <30

Answer 39

>60 = morphine 30-60 = oxycodone <30 = alfentanil

Question 40

Medication(s) for hiccups in palliative care?

Answer 40

Chlorpromazine OR Haloperidol Chlorpromazine is licensed for the treatment of intractable hiccups. Chlorpromazine - antipsychotic medication. Mechanism - central nervous system depressant effects, which can help to reduce the hiccup reflex. Haloperidol is another antipsychotic that can be used first-line. The choice of which antipsychotic to use depends on clinician preference and patient-specific factors.